Treatment of osteochondrosis: motor skill formation

The formation of a motor skill is a multi-stage process. From elementary skills that form the basis of a person's purposeful motor activity and that have become skills as a result of repeated repetition, a transition is made to the synthesis of a whole series of skills and abilities of a higher order. This occurs through the negation of an elementary skill by a skill, and then by a more advanced skill. A skill in this multi-tiered system of voluntary movements is nothing more than a mastered ability to solve one or another type of motor task.

The first stage of motor skill is characterized by irradiation of the nervous process with a generalized external response. The second phase is associated with the concentration of excitation, with improved coordination and the formation of stereotypical movements. The third stage completes the formation of automatism and stabilization of motor acts.

The element of conventionality in such an approach is connected first of all with the allocation of independent phases of the nature of the course of the nervous process. The concentration of the nervous process cannot have a self-suppressing significance. It completes the irradiation of excitation. The phase of generalization in the formation of a new motor skill can coincide with the end of the formation of the previous one. And if phenomenologically, by external signs, it is still possible to judge the completion of a certain stage of the formation of a motor skill, then processes hidden from visual observation are not subject to strict phase analysis.

According to the ideas of N.A. Bernstein, the emergence of automatisms completes the first phase of skill formation. It is characterized by the establishment of the leading level of movement construction, the determination of the motor composition, the necessary corrections and the automation of their switching to lower levels.

The second phase is characterized by standardization of the motor composition, stabilization (resistance to the action of disturbing factors), and consistency of the coordination elements of the skill.

At the stage of skill stabilization, external, random stimuli do not have a destructive effect on it. The quality of the exercise performance is not affected by the complication of the motor situation. Only a long-term change in environmental conditions or a special destruction of the motor structure, due to a change in the established ideas about the technique of performing physical exercises, can significantly change the motor skill or its individual elements. This also applies to a certain extent to the correction of errors in movement. If the error has become an integral part of the learned movement, its correction requires a long time. In some cases, the formation of a new motor skill occurs faster than the correction of an error in it.

The physiological basis for the classification of physical exercises can be:

• muscle activity mode (static, isotonic, mixed);
• degree of coordination complexity;
• the relationship of physical exercise to the development of motor activity qualities (physical qualities);
• relative work power.

Classification of physical exercises by coordination structure provides for the allocation of exercise groups by increasing degree of complexity of body movements and its segments, limbs. The degree of coordination complexity in movements, for example, limbs, will increase from symmetrical movements in one plane to asymmetrical, multidirectional and multiplane movements.

The basis of classification by levels of movement construction is the vertical (from the cerebral hemispheres to the brainstem and spinal cord) hierarchical principle of nervous regulation of movements. This allows us to identify motor acts caused by neural formations at the level of the brainstem, the nearest subcortical nuclei and cortical projections of the motor analyzer.

Method of performing physical exercises: a) standard; b) non-standard (variable).

Thus, cyclic exercises are characterized by standard (constant, unchanging) methods of execution. Non-standard exercises are characterized by constant change of conditions of execution of the movement, and along with it, change of form of movements and their physiological characteristics.

Classification of physical exercises by the level of total energy expenditure was proposed by Dill (1936). Later classifications were also based on this principle. Lonla (1961) proposed classifying work depending on individual energy exchange capabilities by the maximum oxygen consumption (MOC) indicator. Work performed with an oxygen demand exceeding the VO2 max level is classified by him as very heavy.

Acyclic movements are integral, complete motor acts, not connected with each other, having independent significance. These movements are characterized by the relative short duration of execution and an extraordinary variety of forms. By the nature of the work, these are mainly exercises that maximally mobilize the strength and speed of muscle contraction. There is no organic connection between individual acyclic movements, even if they are performed in a certain sequence. Repetition of an acyclic movement does not change its essence, does not turn it into a cyclic one.

Cyclic movements are characterized by a regular, consistent alternation and interconnection of individual phases of the integral movement (cycle) and the cycles themselves. The interconnection of each cycle i with the previous and subsequent is an essential feature of exercises of this type.

The physiological basis of these movements is the rhythmic motor reflex. Selecting the optimal tempo when learning cyclic movements accelerates the process of mastering the rhythm of stimuli, as well as establishing the optimal rhythm of all physiological functions. It helps to increase the lability and resistance of nerve centers to rhythmic stimuli, and accelerates the working-in process.

Synergistic exercises. Under normal conditions, the work of synergistic muscles most often leads to stabilization of the corresponding joints, which facilitates the execution of the main movement. In addition, synergism consists of mutually changing ratios of tension of agonists and antagonists during movement. Synergism is not a constant quality and changes depending on many factors (age, physical condition, illness, etc.). Conditional synergism is created on the basis of reflex arcs. The essence of all synergistic effects is the ability to cause tension of a topographically distant muscle as a result of contraction of another dynamic group.

The following types of synergism should be distinguished: unconditional, conditional, ipsilateral, contralateral.

• Unconditional synergism is an innate neuromuscular reaction fixed in the process of phylogenesis, which is manifested to a greater or lesser extent in each patient. For example: a) in the lower limb - this is straightening of the foot with resistance of the doctor's hands, causing tension of the quadriceps femoris; b) in the upper limb - dorsiflexion in the wrist joint in the pronation position, which leads to tension of the triceps brachii. With palmar flexion in the same joint in the supination position, the biceps brachii is tense; c) in the torso - raising the head in the sagittal plane in the sp. p. - lying on the back causes tension of the rectus abdominis. Raising the head in the sp. p. - lying on the stomach causes tension of the gluteus maximus. Unconditional synergism is used in exercise therapy procedures to activate weakened muscle groups of certain body segments (limbs).
• Conditional synergism exists independently of unconditional synergism and differs from it in principle. The most frequently encountered conditioned reflex synergisms have been identified:
• For the quadriceps:
  • hip flexion;
  • abduction and adduction of the leg at the hip joint;
  • dorsiflexion and plantar flexion of the ankle joint.

ATTENTION! All movements indicated in points "a-c" refer to the limb of the same name.

• transition from starting position - sitting to starting position - lying and reverse movement;
• rotational movements in the hip joint.

• For the gluteal muscles:
  • knee flexion;
  • tilt the body back to the starting position - lying on the stomach;
  • bringing the upper limb of the same name to the initial position - lying on the stomach.

The therapeutic effect of using conditioned reflex synergy may gradually decrease after some time from the start of the exercises. Therefore, every two weeks it is necessary to change the movement that stimulates synergistic contraction in the exercised muscle.

• Ipsilateral synergy is used in exercises performed in adjacent joints of a limb with the aim of causing muscle tension in the same limb.
• Contralateral synergy is the basis of exercises in which movement in the opposite limb is used to excite the muscle.

There are three conditions for the correct performance of synergistic exercises: a) the exercises should cover as many dynamic groups as possible that are responsible for the “transfer” of excitation; b) they should be performed with maximum resistance; c) they should be performed until complete fatigue.

The therapeutic effect through synergistic effects can be achieved by performing exercises 4 times a day.

Therapeutic physical culture as a method of rehabilitation therapy for diseases of the nervous system

Over the past 30-40 years, a large number of methodological techniques have been created aimed at activating the activity of paretic (weakened) muscles and restoring control of anatomically intact muscles by the preserved, but inhibited, motor centers of the spinal cord.

There are three main directions in the development of exercise therapy methods:

1. Functional therapy systems aimed at increasing the patient's overall activity, developing his or her volitional qualities, the desire to overcome stiffness, general weakness, and mastering everyday skills, despite movement disorders and deformations in individual joints.
2. Systems of analytical gymnastics, which are based on the correction of certain deformations, reduction of muscle tone, increase in the volume of voluntary movements in individual joints without taking into account the general motor stereotype of the patient.
3. System of using complex movements.

Functional Therapy Systems

A number of authors believe that the method of therapeutic gymnastics (TG) is determined by the nature of the lesion, the intensity of muscle recovery and the stage of the disease. In this case, active movements should be used as the most complete stimulators of the neuromuscular system. Passive movements are used to stretch shortened (postural) antagonist muscles, improve joint function and develop reflex connections. In order to prevent the development of vicious positions in the patient, it is envisaged to apply special splints, rollers, wear orthopedic shoes, develop correct posture, correct foot placement, etc. Systematic use of massage over many years is mandatory (N.A. Belaya).

For the functional restoration of the affected limbs the following are considered necessary:

• optimal starting positions to obtain maximum range of motion for both healthy and paretic limbs;
• passive movements aimed at preserving joint function involving paretic muscles. These movements promote shortening of paretic (weakened) muscles and lengthening of their antagonists, which is important for the prevention of contractures;
• active movements of healthy and affected limbs. If it is impossible to perform active exercises, a volitional sending of impulses to contract the paretic muscles (ideomotor exercises) or tension of the muscles of healthy limbs - isometric exercises) is used for a reflex increase in the tone of the paretic muscles;
• elementary active movements from easy starting positions, without overcoming the weight of the limb;
• exercises to develop substitution functions through vicariously working muscles or re-education of certain muscle groups;
• active exercises in aquatic environments;
• active exercises with free swinging movements, without force tension:
  • associated (simultaneously with the healthy limb);
  • anti-companion (separately for weakened muscle groups);
• exercises with increasing tension;
• exercises to develop coordination of movements and support functions.

The integrated use of various methods in therapeutic exercise - complex and analytical gymnastics, techniques of the Bobath method (increased training of statodynamic functions), the reduction method according to F. Pokorny and N. Malkova (exteroceptive facilitation), the Kabat method (proprioceptive facilitation) - has found its application in a number of diseases of the nervous system (in particular, in osteochondrosis of the spine).

Among foreign methods of therapeutic gymnastics, the Kenya method (1946) has become widely used. This method is especially widespread in the Czech Republic (F. Pokorny, N. Malkova). Treatment according to this method consists of the following sections:

• hot wraps that improve blood circulation in the affected tissues;
• muscle stimulation is performed in the form of rapidly repeating rhythmic passive movements with simultaneous gentle vibration towards the affected muscles. During stimulation, irritation of numerous proprioceptors of muscles and tendons occurs. As a result, the sending of afferent impulses to the posterior horns of the spinal cord increases, and from there to the motor cells of the anterior horns of the spinal cord, which facilitates rapid restoration of the motor function of the affected muscles;
• Reduction (training of movements) is passive and passive-active movements performed without vibrations, but with an effect on the tactile, visual and auditory analyzers. Reduction consists of several components: first, the instructor must explain and show the patient what movement will be performed. After that, he performs light stroking with his fingers in the direction of movement on those muscles that will contract, and only then proceeds to passive movements.

The optimal time for stimulation and reduction is 5 minutes for each muscle in mild and moderate cases of damage and 3 minutes for severe cases of damage.

Analytical systems

When evaluating analytical systems of exercise therapy in the treatment of patients with diseases and injuries of the nervous system, it is necessary to note the following. The analytical approach allows for the isolated inclusion of individual muscle groups and avoidance of substitutions and complex combinations. However, these systems do not take into account the general patterns of development of motor functions in a child (neurology of childhood) or an adult patient (optimal motor stereotype).

The low efficiency of analytical systems of exercise therapy, especially in the late recovery period of diseases of the nervous system, forced us to abandon the principle of feasible step-by-step physical load in conditions of facilitated movement performance. Another direction has emerged in exercise therapy, which uses “complex movements” in conditions of proprioceptive facilitation to activate the affected muscles. This direction has taken the form of a system known as the Kabot method (Kabot, 1950), or the “proprioceptive facilitation” system, or “Propriozeptive Neuromuscular Facilitation” (PNF).

According to Voss and Knott (1956), this method of exercise therapy was first used in the complex therapy of patients with war injuries. Later, it began to be used to treat various diseases with severe movement disorders.

The numerous techniques offered by the Cabot system are based on the following principles:

• the leading and coordinating stimuli for muscle contraction are proprioceptive stimuli;
• there are related types of movement, where some predispose to other specific types of movement;
• Motor behavior is determined by voluntary (arbitrary) movements.

The Cabot system provides for:

• refusal to gradually increase loads;
• the maximum possible resistance provided to the movement of a segment or the entire limb, or the trunk from the very beginning of therapy;
• analytical work with the affected muscle is excluded; instead of isolated movement of the affected muscle, a complex movement is proposed, covering many muscle groups simultaneously and sequentially;
• one of the factors that facilitates the contraction of a paretic (affected) muscle is its preliminary stretching;
• You should ignore fatigue and engage in an intense program of maximum activity.

The author warns that not all methods are effective for the patient. At first, simpler ones should be tested, then successively more complex or combined methods, until the intended result is achieved.

"Proprioceptive facilitation" is achieved using the following techniques:

• maximum resistance to movement;
• reversal of antagonist muscles;
• preliminary stretching of the affected muscles;
• alternation of antagonist muscles;
• complex motor acts.

A) Maximum resistance to movement can be practically used in the following techniques:

• resistance provided by the instructor's hands. The resistance is not constant and changes throughout the entire volume during muscle contraction. By providing resistance, the instructor makes the patient's muscles work throughout the entire movement with the same force, i.e. in an isotonic mode;
• alternation of muscle work. Overcoming the "maximum resistance, the exercised part of the limb (for example, the shoulder) moves to a certain point of movement. Then the trainer, increasing the resistance, prevents further movement. The patient is asked to hold this part of the limb in a given position and, increasing the resistance, achieve the greatest muscle activity in the isometric mode of work (exposure 2-3 s). After which, reducing the resistance, the patient is asked to continue the movement. Thus, isometric work turns into isotonic;
• repetition of muscle contractions; voluntary muscle contraction continues until fatigue sets in. Alternation of muscle work types, performed several times throughout the movement.

B) A quick change in the direction of movement, called reversion, can be performed in various variations both with the full amplitude of movements in the joint and in its individual parts. With slow reversion of the antagonist muscles, the movement with resistance in the direction of their contraction is performed slowly, with a subsequent transition to movements with resistance of the paretic muscles. In this case, the consequence of the stimulating proprioceptive effect is used, since due to the tension of the antagonists, the excitability of the motor cells of the spinal cord that innervate the paretic muscles increases. The patient can be asked to hold the distal part of the limb at the end of the movement (exposure 1-2 s) and without a pause move on to performing the opposite movement. Slow reversion of antagonists with isometric holding and subsequent relaxation or slow reversion of antagonists with subsequent relaxation are also possible.

Rapid execution of movements towards the paretic muscles after slow maximum resistance of the antagonist muscles is called rapid reversion of the antagonists. The speed of contraction of the paretic muscles can be increased by weakening the resistance or by helping the patient. It is necessary to finish the rapid movement with static holding of the limb, while providing maximum resistance.

B) Preliminary stretching of the affected muscles can be carried out in the form of:

• passive muscle stretching. The limbs are placed in a position that stretches the paretic muscles by flexing or extending several joints. For example, to train the rectus femoris, the lower limb is first extended at the hip and bent at the knee. This technique stretches and prepares the rectus femoris for contraction. Then this muscle is exercised by extending the knee;
• rapid stretching from a fixed position of the limb. By resisting the antagonists, the instructor asks the patient to fix the limb in a given position, maximally activating the work of the unaffected muscles. Then the resistance force is reduced and movement of the patient's limb is caused. Without bringing the movement to its full volume, the direction of movement is changed to the opposite, i.e. weakened muscles are included in the work. Consequently, the contraction of paretic muscles occurs after their preliminary rapid stretching;
• rapid muscle stretching immediately following an active movement. Overcoming maximum resistance, the patient performs a slow movement. Suddenly, the instructor reduces the resistance force, which leads to a rapid movement. Without bringing the movement to its full volume, the direction of the movement is changed to the opposite by engaging the affected muscle groups.

D) Alternation of antagonists:

1. Slow alternation of isotonic contractions of antagonists within the framework of the movement being performed (limb segment). Movement: maximum contraction of the agonist. With dosed resistance, followed (also with resistance) by contractions of the antagonist.

CAUTION! The stronger the contraction of the agonist, the greater the facilitation (assistance) of the antagonist. It is important to achieve maximum resistance in the contraction of the antagonists from the very beginning, before resistance is provided to the weaker agonist.

The contraction should be performed slowly to allow for optimal arousal.

1. Slow alternation with static effort is an isotonic contraction followed by either an isometric contraction or an eccentric contraction involving a limited volume of the same muscle group. This methodical technique is applied immediately after this, using antagonistic muscle groups. For example, when bending the arm at the elbow (isotonic mode), the therapist stops the movement at an angle of 25° and asks the patient to continue contracting the flexor muscles with the maximum possible force (isometric mode of work), resisting the movement with his hand. Then the therapist asks the patient to perform extension and blocks this movement, resisting, at the level of maximum amplitude or at the end of it.
2. Rhythmic stabilization is the blocking of movement (resistance by the doctor's hand) at a certain amplitude, followed by blocking of movement in the opposite direction. Thus, we block, for example, in one of the diagonal schemes: flexion and rotation of the hip, increasing the resistance, forcing the muscles to contract isometrically at the same time; after this, the doctor immediately asks the patient to perform hip extension and rotation in the opposite direction, a movement that is also blocked.
3. Slow alternation - relaxation is achieved by applying the procedure indicated in the first point, after which each contraction is followed by relaxation, until a new isotonic contraction is reached.
4. Slow alternation with static effort and relaxation consists of applying the procedure of the second point, followed by the maximum possible relaxation of the muscles.
5. A combination of the procedures of points 4 and 5 in the sense of using slow alternation with relaxation (after isotonic contraction) for the antagonist and slow alternation with static effort and relaxation (after isometric contraction) for the weaker agonist.

ATTENTION! The last three procedures are used to relax tense muscles. The moment of relaxation is important in these procedures. The relaxation time should be long enough for the patient to feel this effect and the doctor to be sure that the maximum possible relaxation has been achieved.

D) Complex motor acts are carried out by the joint contraction of paretic and intact or less affected muscles. In this case, not individual contracting muscles (or muscles) are trained, but significant muscle regions participating in significant and complex motor acts that are most characteristic of the patient.

The author notes that the pattern of movements of daily normal human activity, requiring a certain amount of effort at work and during activities such as health-improving physical training, is performed along a diagonal trajectory relative to the vertical axis of the body. Movements used in this way are more effective and correspond to the possibilities of using the maximum possible force, since:

1) allows you to correctly anatomically distribute certain muscle groups and influence them;

2) these schemes involve a large number of muscle groups in movement, the treatment covers a large number of interested muscles at once and thus leads to faster results.

The exercises are performed with resistance provided by blocks (with weights), dumbbells, expanders, etc. It is possible to use simpler schemes, where resistance is provided by a series of actions, such as: crawling forward, backward, to the side, etc. These exercises are performed sequentially - from simple to complex and more complex (starting position - lying down, standing on all fours, on your knees, in a half-squat, etc.).

Complex movements are performed along all three axes: flexion and extension, adduction and abduction, internal and external rotation in various combinations along two main diagonal planes. Movements toward the head are considered flexion (based on the nature of movements in the shoulder and hip joints), movements downwards and backwards from the head are considered extension, toward the midline are considered adduction, and from the midline are considered abduction.

In the first diagonal plane, the limb moves toward the head (upward) and toward the midline (flexion-adduction), and in the opposite direction - downward and outward (extension-abduction). In the second diagonal plane, the limb is directed upward and outward (flexion-abduction), in the opposite direction - downward and inward (extension-adduction).

Flexion-adduction is combined with external rotation and supination, extension-abduction - with internal rotation and pronation. Symmetrical and asymmetrical exercises are used, which should be performed from the distal parts of the limbs, using the overcoming, yielding and holding forces of the muscles. Movements (in two opposite directions) are allowed in two joints (for example, in the shoulder and elbow, hip and knee). Head turns in the direction of movement are allowed.

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Unconditioned tonic reflexes in the formation of voluntary movements

Innate motor reflexes ensure the maintenance of normal posture, balance, and coordinate posture with the position of the head in relation to the body.

According to the existing classification, innate motor reflexes are divided into:

• on reflexes that determine the position of the body at rest (position reflexes);
• reflexes that ensure a return to the initial position (righting reflexes).

Position reflexes occur when the head is tilted or turned due to irritation of the nerve endings of the neck muscles (cervical tonic reflexes) and the labyrinths of the inner ear (labyrinth reflexes). Raising or lowering the head causes a reflex change in the tone of the muscles of the trunk and limbs, ensuring the maintenance of a normal posture.

Physical rehabilitation means in the treatment of osteochondrosis of the spine

Righting reflexes ensure the maintenance of the posture when it deviates from the normal position (for example, straightening the trunk). The chain of righting reflexes begins with raising the head and subsequent change in the position of the trunk, ending with the restoration of the normal posture. The vestibular and visual apparatus, muscle proprioceptors, and skin receptors participate in the implementation of righting reflexes.

The production and everyday activities of a person are connected with continuous changes in the interaction of the organism and the environment. Mastering the complex technique of physical exercises under changing external conditions (for example, in a game environment, coordination exercises, etc.) is an example of such interaction. The development of the finest differentiations that allow one or another exercise to be performed rationally is the result of the analytical and synthetic activity of the brain. On the basis of this activity, the system of control of voluntary movements is formed.

In France, a method of sequential education of motor functions based on developed static postures and balance reactions has been proposed. The authors propose a number of physical exercises aimed at activating the trunk extensor muscles. Balance training is carried out using the cervical tonic asymmetric reflex. From the same standpoint, the method of spouses K. and B. Bobath (Bobath Karela et Berta) deserves attention, which consists in inhibiting abnormal tonic reflexes, in pushing through higher coordinated postural reactions in a certain sequence with a constant transition to voluntary movements and regulation of reciprocal muscle activity. Inhibition of pathological postures and movements in patients with spastic paralysis of the head, neck or shoulder girdle. Therefore, in the method of K. and B. Bobath, much attention is paid to the correct use of tonic reflexes.

The main tonic reflexes are:

• tonic labyrinthine reflex, dependent on the position of the head in space. In the supine position, hypertonia of the back extensor muscles is caused. The patient cannot raise his head, move his shoulders forward, or turn on his side. In the prone position, the tone of the back flexor muscles increases. The torso and head are bent, the arms are pressed to the chest in a bent position, the legs are bent at all joints;
• asymmetrical tonic reflex (cervical). Rotation towards the head causes an increase in muscle tone in the limbs on the half of the body corresponding to the rotation, while on the opposite side the muscle tone in the limbs decreases;
• symmetrical tonic neck reflex. When the head is raised, the tone of the extensors of the arms and flexors of the legs increases, when it is lowered, on the contrary, the tone of the flexors of the arms and extensors of the legs increases;
• association reactions - tonic reflexes that begin in one limb and increase the muscle tone of the other limb, which, when repeated frequently, contributes to the development of contractures. The main pathology of motor skills is the disruption of the normal mechanism of automatic balance and normal head position. Distorted muscle tone causes pathological positions that impede movement. Depending on the position of the head in space and its relationship with the neck and body, the tone of various muscle groups changes.

All tonic reflexes act together, harmoniously strengthening or weakening each other.

Features of the technique:

• selection of initial positions that inhibit reflexes. For example, in the initial position - lying on the back (in this case, the spasticity of the extensor muscles is increased), the head is moved to the middle position and bent forward. The arms are bent at the shoulder and elbow joints and placed on the chest. The legs are bent and, if necessary, abducted. In this way, a position is created that allows stretching all the spastically contracted muscles.